A tricky diagnosis: Dorsalis pedis artery impingement

There are straightforward diagnoses, there are tricky diagnoses, and there are diagnoses like Ella Johnson’s.

Figuring out and ultimately solving her mysterious foot pain took a team of vascular and orthopedic specialists with a big assist from Ella’s mom.

Ella Johnson, a junior at Cherry Creek High School, noticed a tingling and burning in her right foot after running on a treadmill. Her mysterious foot pain was diagnosed as dorsalis pedis artery impingement. Photos by Cyrus McCrimmon for UCHealth.

The mysterious foot pain

Ella, then 16, was a junior at Cherry Creek High School when she noticed a tingling and burning in her right foot after a run on a treadmill. Ella was no stranger to running: she was on the cross country team. The discomfort went away after an hour or so, and she didn’t think much of it. She figured it probably had to do with her Raynaud’s disease, which can leave the fingers and toes numb when one is cold or, in some cases, feeling stressed.

Coincidentally, that particular treadmill run had been shortly before Thanksgiving 2018 and the weather had been cooling off. But Raynaud’s couldn’t explain the more consistent pain she started to feel in the toes of her right foot. Ella’s mom Danette also noted that those toes looked slightly whiter and bluer than the ones on the left, hinting at a blood-flow problem.

“It looked to me like there was an arterial deficiency,” said Danette, who thankfully has extensive knowledge of such things.

She’s a physical therapist who focuses on wound care at a local medical center. Danette also noted that her daughter’s mysterious foot pain seemed worse in the morning, so there was a pattern.

Danette and Ella’s doctors were trying to figure out what to do when Ella wore high heels to school one day. She called her mom in tears. Danette took Ella to the emergency room at a local medical center, where an ultrasound of Ella’s foot found nothing out of the ordinary. Danette also called a colleague, who noted that when he moved Ella’s foot such that the foot was extended like that of a ballerina on pointe (plantarflexion), the pulse in Ella’s foot disappeared. Something strange was going on. The doctor called Dr. Will Hiatt, a vascular specialist at UCHealth University of Colorado Hospital on the Anschutz Medical Campus. Hiatt had a long track record of solving vexing puzzles related to arteries and veins.

Rare case

In the meantime, a colleague of Danette’s had come across a journal article describing a case of something called dorsalis pedis artery impingement in a 17-year-old Irish dancer. The dancer also happened to have Raynaud’s disease. What struck Danette was that the pain and numbness in the young dancer’s feet had been worse after plantarflexion, just as it was with Ella. Ella often slept on her stomach with the mattress pressing her toes into a pointed position. Maybe that was why the pain was most extreme in the morning.

By early 2019, things had progressed. Despite wearing a night splint, her mysterious foot pain had moved to the point that Ella was in a walking boot. Running was out of the question, as were activities like ice skating, sledding, or going to the mall with friends.

Ella Johnson had her mom, Danette, a physical therapist, by her side while doctors worked to understand Ella’s mysterious foot pain.

Ella and Danette met with Hiatt, who spent time evaluating her medical history and the nature of the problem. He then set the wheels of the hospital’s integrated vascular program in motion. The first step was a duplex ultrasound, which captured both the structure of blood vessels and the nature of blood flow in Ella’s feet. The left foot checked out fine. But sure enough, when Ella plantarflexed her right foot, blood flow stopped and then returned to normal with her foot in a neutral position. Ella and the Irish dancer, shared the same rare foot disorder. Over the course of a decades-long career in a university medical center where tricky cases referred from outside specialists are the norm, Hiatt had not seen arterial impingement at this location – although he was quite familiar with compression of the popliteal artery behind the knee due to similar a similar condition.

The Irish dancer’s problem had been solved by surgically removing three fibrous bands that were choking off blood flow to the foot. An MRI of Ella’s foot found no such obvious culprit, but showed hints that perhaps an overgrown foot muscle and an atypical tendon arrangement were conspiring to similar effect. Whatever the cause, the fix would demand vascular as well as orthopedic surgical expertise. Dr. Jason Stoneback, an orthopedic trauma specialist and director of the UCHealth Limb Restoration Program; and Dr. Max Wohlauer, a vascular surgeon, would perform the surgery together.

The two surgeons and others associated with the UCHealth vascular surgery and Limb Restoration programs had collaborated many times before in fixing serious injuries to arms and legs. Ella’s foot, while less-obviously damaged, needed restoration too. That her particular malady was new to the team wasn’t a serious concern, Stoneback says.

“This is what we do – it’s the nature of the Limb Restoration Program. We take really tough cases and handle extremely rare conditions,” Stoneback said. “You become good at doing things that people have never seen before.”

Restoring the flow

The surgery happened in late February 2019 in a state-of-the-art hybrid operating room where Wohlauer could inject contrast into her leg arteries to pinpoint the area where the tendon was compressing the artery in the foot. Stoneback went to work and found what he described as “a combination of tight tissues and a tendon and muscle running in an abnormal way in her foot over the artery.” He moved and re-anchored the tendon to a place where it could still do its job without choking off blood flow and causing Ella pain. Wohlauer cleared off fibrous bands constricting the artery. The procedure was done in a couple of hours.

Ella Johnson is back to playing powder puff football after doctors diagnosed her with dorsalis pedis artery impingement.

Blood now flowed to through Ella’s right foot regardless of ankle position. She was in a cast for a couple of weeks. Danette, who did double duty as mom and physical therapist, then kept Ella in the walking boot for eight weeks to ensure that the displaced tendon had settled in firmly at its new home. The day Ella left the boot behind couldn’t come soon enough: She had a May 6 deadline to meet.

“I wasn’t going to wear a boot to prom,” she said.

Four months after her walking-boot-free prom, a four-inch scar atop her foot was the only remnant of a medical mystery solved. Now a senior at Cherry Creek, she was playing on a “powder puff” flag football team that practiced or played each Sunday afternoon. She couldn’t have done it without her mom’s sleuthing and her UCHealth doctors’ diagnosis and surgery.

“They were so open and willing to look for something different and outside the normal,” Danette said. “That’s why they’re the perfect resource for people who have exhausted their options with primary care doctors or elsewhere.”

Stoneback and Wohlauer have done more complex surgeries, but none more gratifying.

“Ella has made a remarkable recovery,” Wohlauer said.

“She went from not being able to walk properly to playing flag football,” Stoneback added. “It’s awesome. It’s what we’re about here.”

About the author

Since 2008, Todd Neff has written hundreds of stories for University of Colorado Hospital and UCHealth. He covered science and the environment for the Daily Camera in Boulder, Colorado, and has taught narrative nonfiction at the University of Colorado. He was a 2007-2008 Ted Scripps Fellowship recipient in Environmental Journalism at CU.

His latest book, "The Laser That’s Changing the World," tells the story of the inventors and innovators who saw, and ultimately realized, the potential of lidar to help solve problems ranging from smokestack-pollution detection, ice-sheet mapping, disaster recovery, and, ultimately, autonomous-vehicle guidance, among many other uses. His first book, "From Jars to the Stars," recounts how Ball Aerospace evolved from an Indiana jar company - and a group of students in a University of Colorado basement - to an organization that managed to blast a sizable crater in the comet 9P/Tempel 1. "Jars" won the Colorado Book Award for History in 2012.

Todd graduated with a business degree from the University of Michigan, where he played soccer, and with a master’s degree from the Fletcher School of Law and Diplomacy at Tufts University. Before becoming a journalist at the turn of the millennium, he was an IT and strategy consultant. He once spoke fluent Japanese and still speaks fluent German.

When not writing, he spends time with teenage daughters and wife Carol, plays soccer, and allows himself to be bullied by a puggle he outweighs by a factor of seven.